Harm Reduction vs. Abstinence: A Case Study

Harm Reduction vs. Abstinence: A Case Study

Disclaimer: This blog isn’t an opinion piece either way about the efficacy of either approach to recovery. At the end of the day, the circumstances of an individual are never identical to those of another. TWC believes in providing the tools for men of all ages and backgrounds to achieve meaning, purpose and a new life in recovery.

The Social Impact of Drugs

Canada has long been a very progressive country in many areas, and although we had our own “War on Drugs”, there has consistently been much compassion for those addicted to illicit substances. We promote individual choice, freedom, and healthcare. These concepts are noble, well-intentioned and have widespread support. The question then becomes: when someone is addicted to drugs to the point that they can no longer function in society, what do you do about the fact that drugs are taking away the individual choice, freedom and their health?

For those of us who live in Vancouver, the Downtown Eastside is a constant reminder of the ravaging effect of drugs on society. The last decade has seen the numbers of those suffering swell and resources pushed to the breaking point. The point is regularly made that many of those who are homeless and living in insufferable circumstances whilst addicted to drugs also suffer from mental illness. This argument is valid, albeit in part. The closing of Riverview and other facilities undoubtedly exacerbated the situation, but pointing to a single cause for a complex issue is almost always ill-informed. Many people living normal lives in society deal with mental illness; many mental illnesses are manageable.

In a perfect world, everyone who is addicted to drugs would stop using those drugs. The evidence shows, and irrefutably so, that not everyone who is hooked on drugs will magically be able to stop. Ever since alcohol was first distilled sometime between 3000 and 2000 BC, or 4 to 5,000 years ago, there have been alcoholics. The phenomenon of drug and alcohol dependence isn’t going anywhere – so what to do about it?

There are differing opinions about the root causes of addiction, which, for the purpose of this article, we are not going to get into. We’re going to explore the differing approaches to treating addiction: Harm Reduction and Abstinence.

What is Harm Reduction?

Harm Reduction, which aims to reduce both the societal and individual impacts of addiction is a concept that was implemented in the 1960s and really expanded upon over the following decades. Methadone was the first treatment that widely became available. Methadone is a long-acting synthetic opioid (analgesic) drug used as a substitute in the treatment of morphine, heroin, and now, fentanyl addiction. Relatively uncontroversial, methadone used by itself, without supplementing it with other drugs, allows the individual to lead a generally regular life.

In the 1980s as HIV (Human immunodeficiency Virus) and Hepatitis C began to spread and really take its toll on the intravenous drug-use community, needle exchange programs and supervised injection sites began to pop up in some Western countries.


(info from postmedia.com and vancouver.ca)

1984: World’s first needle exchange opened in the Netherlands.

1986: First legal, supervised injection site opens in Switzerland

1989: First Canadian needle exchange program opens in British Columbia. It is operated as a pilot project for the Downtown Eastside and is funded by the city of Vancouver.

1991: British Columbian patients registered or methadone maintenance program is 1,221. By 2017 there are 27,553 with a projection of 58,000 by 2020.

1996: The B.C. Centre for Excellence HIV and AIDS starts a study on injection drug users.

1997: Vancouver declares a public health emergency in response to increased overdose deaths, Hep A, B and C, syphilis and HIV infections.

2001: Vancouver city council approved the Four Pillar Approach (harm reduction, prevention, treatment and enforcement).

2003: First legal supervised injection site in North America opens in Vancouver Downtown Eastside.

2005-2010: Stigma acknowledged as key factor harming socialization of addicts, Vancouver regularly highlights the failure of drug prohibition and urges Federal government to consider alternatives.

2016: Another public health emergency declared, this time by B.C.’s provincial health officer in response to increasing numbers of drug overdoses and deaths.

2016-2019: Over 10,000 Canadians succumb to fatal overdoses. Life expectancy in B.C. bucks a 40+ year trend of gradual increase and falls for 2 years in a row because of overdose and suicide.

Everyone in Canada can get behind minimizing the impact, both to the individual and society as a whole, of a problem that costs our country billions of dollars annually and causes mass death. The other aspect is that since we have a social healthcare model, Canadians should be entitled to the type of care that works best for the disease they are dealing with, which, in this case, is obviously addiction. One of the primary criticisms of harm reduction, as implemented in B.C., is that it focuses too heavily on substitute drugs and supervised injection and not enough of housing, job programs, counselling and treatment. The Four Pillar Approach, which proved unbelievably successful in all but eradicating homelessness and drug-related diseases in Switzerland have actually seen the same things increase in Vancouver. Harm reduction by itself is certainly not to blame, but an over-reliance on harm reduction alone may, in fact, be.

What is Abstinence?

Abstinence is defined as the practice of restraining oneself from indulging in something, typically drugs or alcohol. The movement, which came to prominence with the creation and growth of Alcoholics Anonymous (founded 1935), and now known as the Minnesota Model (Abstinence Addiction Treatment) is based on the fact that addiction is a chronic and progressive disease that is not curable but that indeed may be arrested. In short, the concept is basically about stopping using whatever it is that you are using, and then staying stopped.

The primary selling point for abstinence-based addiction treatment is that when the individual becomes free of their debilitating vice, their quality of life will have the optimal ceiling. The chemical-free person will be free from any crutches, have as clear of a mind as possible, and will be able to fully pursue anything it is that they desire.

Tenets of Abstinence Treatment

  1. Addiction is a chronic and progressive disease
  2. Addiction is not something you choose and can be diagnosed.
  3. Addiction is not curable but can be treated
  4. Whether or not someone wants to seek treatment at first is not a predictor of long-term success or failure.
  5. Treatment must be physical, social, spiritual and psychological
  6. The addict/alcoholic will need a support system and community
  7. The addict/alcoholic must get out of the victim mentality, possibly with much counselling required, and become accountable for their part.
  8. Addiction is not the individual’s fault, but personal recovery is their responsibility.

Although abstinence-based care no doubt has many benefits, especially when dealing with alcohol, benzodiazepines and accelerants, in particular, there is a good argument that science or medication-based approaches can be beneficial as well. For instance, one of the barriers to treatment is the fear of detox for some drugs. The risk of fatal opiate overdose is reduced when the tolerance to opioids is increased, but then with increased tolerance, the likelihood that the individual will use a larger quantity of drugs is increased as well.


As mentioned in the first portion of this article, there are no two sets of individual circumstances that are identical. While one person might thrive in abstinence on their first try, someone else might barely get a day of sobriety despite trying for years. No one argues that in a perfect world, no one would need any medications. No one wants to require an anti-depressant, but guess what? The person who needs their anti-depressant then often gets to live a phenomenal life. Diabetics don’t like taking insulin, but it sustains them.

The main thing, though, is that abstinence or harm-reduction alone simply don’t suffice. The issues that lead to debilitating addiction are deeper than just taking the substance or not. People need meaning and a sense of purpose in their life. We need stability, optimism and a real way forward. Everyone who has been hooked to drugs or alcohol knows they can find that momentary numbing by going back. But that momentary numbing is never worth the long term consequences.

“You can halt the supply, but that won’t stop the demand; you can halt the demand, but that won’t stop the supply; stopping supply and demand at the same time has up until now proved impossible; so you need to get to the root cause.”

Written for Together We Can by Tristan Elliott, a third-year BBA student who currently works as the Marketing & Communications Coordinator. He is passionate about issues affecting the local community, personal finance, the economy, and Canada as a whole.

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